Wednesday, January 13, 2010

Reflections from a Monday in Clinic at Grady: Fearfully and Wonderfully Made

Mount Everest

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4:25 p.m.

"Ms. Bates! Ms. Geraldine Bates!(name changed)," my voice rang out over the waiting room in the Primary Care Center. I waited a few moments for someone to begin shuffling in their seat, and collecting their coat, hat and WordFind books. No answer. "Ms. Geraldine Bates!" I spoke louder, this time craning my neck around the door to be sure those on the other side of the room could hear. Not a peep.

I've been working at Grady for nearly a decade, and if I haven't learned anything, it is this: Nothing is ever what it seems. You mean to tell me it's 4:25 p.m., and the last patient of the day is a no show? As my Auntie Deirdre always says, "Chile' please." There is no way that it would go down like that on a Monday afternoon in the Grady Primary Care Center. If it seems too good to be true--which getting out early on a Monday seems--then indeed it is.

Back in the day, I did the obligatory "name call," and even paced through the waiting area in case someone was hard-of-hearing. If nobody bit, (doing little to hide my excitement)I would make a beeline for my purse and coat, and then bolt for the nearest stairwell. A patient who doesn't answer is what we affectionately call a "dinka" -- our slang term for the person who did not keep their appointment. It took me only one or two times to learn my lesson. I'd get my mind all set on an early departure only to have my bubble burst by a nurse giving me that nauseating page (sometimes answered from the parking lot, uggghh!) that I overlooked somebody sleeping in the waiting area. "Oh yeah, and he is elderly," they always added, "and looks like he is breathing kinda hard." Damn.

Now, I know better. Geraldine Bates would not be deemed a "dinka" until I shook every shoulder of every dozed off thing in the room--animal, vegetable or mineral. I strolled through the room, looking from side to side. I stopped in front of a very obese, disheveled appearing woman leaning back in one of the vinyl arm chairs that lined the walls. The back of her head was wedged between the wall and the top of the chair, and her mouth was wide open. She was completely still, almost like a corpse. Several plastic bags, full to the brim, were scattered around her swollen feet which were bursting out of unlaced, run down sneakers. A dank odor that seemed to be some murky combination of must and urine wafted across my nose as I looked down at the chart in my hand. 43 years old. Although I couldn't place an exact age on this sleeping patient, my guess was that this was indeed my absentee.

Suddenly, she released an intrusively loud snore; more like the cross between an angry growl and someone biting the crunchiest apple ever. It cut through the air like a noxious siren, signaling danger to all around. In addition to startling me, she jolted herself awake, immediately attempting to save face by sitting up in her chair and looking industrious. Some of the other patients graciously continued to thumb through their magazines or keep their eyes glued on the television, while the less-kind raised their eyebrows, shook heads, or even audibly chuckled. The patient batted her now bloodshot eyes and gave me a bewildered stare.

I lowered my voice and asked, "Are you Ms. Geraldine Bates?"

"Yeah ma'am," she replied in a throaty, almost congested sounding voice. She leaned over to collect what appeared to be everything she owned from the floor. I placed the chart under my arm and pitched in by picking up two bags as she slowly followed me back to the examination room.

I gestured for her to enter room 51 and went to find a larger sized blood pressure cuff, knowing the ones I had would never work. The minute I reentered the room, I was struck by how rapidly her pungent body odor had permeated every corner of the small space. I made a decided effort to respect her enough to show no reaction.

"I'm sorry about how I smell," she instantly apologized. I could feel my face flushing, embarrassed that perhaps I'd been one of those less-kind people with a poorly camouflaged facial expression. "Sometimes it is hard to get to a restroom with all my stuff, and I don't always have access to a shower or nothin'."

"It's okay," I replied with a smile. I held out my hand. "I'm Dr. Manning. How're you doing today, Ms. Bates?" She sat there looking at my hand for a moment before reaching out to shake it.

"Umm, I'm, umm, okay," she responded.

"What brings you here today, ma'am?" I inquired while connecting the blood pressure cuff to the wall.

"I 'on't know," she answered initially, "Well, no. Yes, I do know. I get tired a lot." She didn't have to tell me that. Her outburst in the waiting room was nearly diagnostic of sleep apnea. I wish I'd had a few medical students with me to witness it; it would have been a teachable moment for sure.

"And my head hurts sometimes, too, especially in the morning 'cause I feel like I haven't rested. I feel like I falls asleep all the time but don't never get no rest. It's crazy."

"Has it been like this for a while?"

"Yeah ma'am. I be tired all the time. Then I stay in the shelter, and they make you get up early and get out. I be so tired, doctor. I be outta wind and short at the breath." She shook her head for emphasis. "It's hard, doctor." It sounded hard.

"I bet," I said while looking at her closely, "Have you ever seen a doctor for this. . . I mean the tired feeling?" I took a mental picture. Her eyes were defeated and tired appearing. The dark skin of her neck was even darker in the creases; accentuated by a velvety pigmentation. Each of her fingernails had a perfect strip of black dirt deeply embedded below the nailbed. She tucked them under her jacket when she caught my eyes resting on them.

"One time they said I had the sleep apnee," she spoke, "and they gave me a machine. I was 'posed to put it on when I sleep, but then one time I fell asleep in the Marta station and somebody stole it. But that was a long time ago."

"Dang," I caught myself saying out loud. I went through the rest of her current and past medical history, and then proceeded to examine her. Blood pressure was elevated, otherwise the exam wasn't that remarkable with the exception of her weight. I helped her down from the exam table as we prepared to discuss the assessment and plan for her.

I sat there staring at the chart in front of me. This is so whack, man. What am I supposed to do? I mean really do? Ms. Geraldine, I want to help you, but will you fire me if I admit that I don't know how to help you? Will you scream at me if I throw my hands up and say I wasted your time today? I felt like my arms were being pinned at my sides and I couldn't move. What kind of "plan" exactly could I offer? I mean, sure, I can write a whole bunch of things, but I mean, a real, bonified, helpful plan? I wasn't feeling that positive.

Plan:

1. Discuss weight loss strategies. Refer to nutrition. For what? She doesn't have any groceries. Just say "no" when Meals on Wheels gives you a fat-laden free meal or when a nice stranger offers to buy you a two piece meal at Popeye's.Prescription for exercise discussed. Yeah. Carry everything you own on your back for ten miles every day with swollen legs. I know, Ms. Geraldine. My exercise prescription is not so realistic for you.

2. Refer for sleep study to confirm diagnosis of Obstructive Sleep Apnea. Yes. Schedule her for a sleep study with a co-pay she can't afford. Attempt to get records from prior sleep study, if available. Then I can get her a CPAP or BiPAP machine so somebody can steal it.Great.

3. Start Hydrochlorothiazide 25 mg, start Amlodipine 5 mg. Wait, Amlodipine could make her legs swell and her legs are are already swollen.Change that Amlodipine. Atenolol 25 mg. Anticipate improvement in B.P. with management of #1 and #2.

4. Anticipate improvement of swelling/edema with management of #1 and #2. Check echocardiogram to evaluate heart function. Compression stockings. I know they will make you miserably uncomfortable, Ms. Geraldine, and will be very difficult to put on, but yeah, lets do that, too.

5. Refer to social services. Our social worker is awesome, but she is human. Please don't fire me, Ms. Geraldine.

Let's add this to the plan:

6. Get you a loving home and a rolodex full of family support. Remove any self-loathing that you have and replace it with extraordinary self esteem. Get you money and the knowledge of how to manage it. Place you somewhere safe with a nice fridge and access to fresh foods and fresh air. Inspire you to find a career you love and to leap from bed every day to exercise and to do fulfilling things that change the world.

I half-heartedly reviewed my plan with Ms. Bates who seemed surprisingly okay with it. I tried my best to smile and look positive while answering her questions. I placed my chin in my palm and sighed, finishing up her prescription. I wished there was someone who could help me achieve #6 on my plan.

"You okay, doctor?" she asked me, turning the tables. She meant it. She really wanted to know if I was okay.

She picked at her gritty nails. "They in Athens and here. But I don't have nobody." Nobody? You don't have NOBODY?

"Why not? What happened?" I quickly replied, again smacking myself on the back of the head for being so forward. "I mean. . . .you're young. . . . like. . . how did this happen?"

"What? Me being homeless or me being. . . ." she cast her eyes downward toward her body, ". . .being like this?" I hoped it was a rhetorical question. Shoot! I offended her! Wait, did I? She sighed and shook her head slowly. "I don't even know, doctor. I mean. . . .I guess nobody paid attention to me, you know? And when they did pay attention, it wasn't the good kind of attention. Mama passed on when I was in the 9th, so I didn't finish. Don't have no relationship with my daddy. Then when I got big like this, it's like I went away. Nobody want nothing to do with me. Stankin' all the time, can't do nothing. I don't blame 'em."

My arms went from pinned to tightly restrained with handcuffs behind my back. I felt a small wave of nausea along with an almost overwhelming urge to run out of the room. I didn't know what to say. She is still a person. Just go with that.

"Oh, Ms. Geraldine," I said softly. It was all I could think to say. I placed my hand on top of hers and smiled. "You know, Ms. Geraldine--I always tell my kids this--'You were fearfully and wonderfully made.' It kind of means that we are all special. The same goes for you."

"Your kids is lucky," she stated wistfully, "I bet you they feel good about who they are." Wow.

I tapped my foot on the floor beneath the desk to let out the emotion mounting inside of me. This is not fair. This is so whack. This is the part of my job I intensely hate and love at the same time.

"I sure hope so, Ms. Geraldine," I sighed. I looked her in the eye and placed my hands down firmly on the desk. "Let's do this. How about you keep your appointments with us, and see our social worker, Ms. Beasley today? We'll take this thing one day at a time, okay?"

She smiled wide and nodded. "One step at a time," she cosigned.

I shook her hand and walked over to the door. "And maybe when this is all said and done, you'll feel good about who you are, too, Ms. Geraldine."

There are sometimes those days caring for patients in a public hospital like Grady where you feel like a tiny ant gazing upward at the Mount Everest of medical problems--without so much as one rope or one pick with which to climb. At those times, I try to remember what I always tell my medical students and myself: Patients are people. Patients are people. Patients are people. This is where we all intersect; different lives, different upbringings, different cultures, different circumstances--but all people with wishes and hopes and dreams. Remembering that human aspect and tapping into it can be the first step. . . . .and sometimes it's the only way to empower our patients to conquer their own mountains.

". . .I am fearfully and wonderfully made; Your works are wonderful, I know that full well."

4 comments:

I am a first-year medical student, and I know you ;). Thanks for writing about one of the things I think about the most...how do you start to make an impact when culture, history, and habit are stacked against the two of you (patient and physician)? How do you, with your privilege, not sound smug? I think you hit the nail on the head: you start somewhere, with unmeasurable compassion. Thanks for writing.

There is a book written by Fr. Robert L. Arpin entitled "Wonderfully,Fearfully Made". Candid and openhearted letters written by a gay priest living with AIDS. Reading his words often brought tears to my eyes as did your caring and compassionate reflections on Ms. Geraldine. THANK YOU!

I am a public school teacher. I was assigned to read Understanding Poverty by Ruby Payne when I was in school for my EdSp degree, which turned out to be the most helpful of any book I ever read in school. It has really helped me in my understanding of kids stuck in the cycle of extreme poverty. I hope I can help keep at least one student from becoming "Geraldine," from giving up on life. May God bless us greatly to help a world that is hurting.

I know this is an old post, but I read your blog every morning before I start my day and when you haven't posted something new I go to the archives! This post was absolutely beautiful. My parents didn't completely shelter me from the world, but when I get insights like these into the lives of people struggling with abject poverty, it opens my eyes to how strongly my view of others is skewed by the privilege I just happened to be born into. please don't ever stop writing Dr. Manning!

Welcome to Atlanta.

"Becoming is better than being." - Carol Dweck

Who me? I'm just glad to be here.

Honestly? I write this blog to share the human aspects of medicine + teaching + work/life balance with others and myself -- and to honor the public hospital and her patients--but never at the expense of patient privacy or dignity.
Thanks for stopping by! :)

What's the point?

"One writes out of one thing only--one's own experience. Everything depends of how relentlessly one forces from this experience the last drop, sweet or bitter, it can possibly give."

~ James Baldwin (1924 - 1987)

"Do it for the story." ~ Antoinette Nguyen, MD, MPH

Details, names, time frames, etc. are always changed to protect anonymity. This may or may not be an amalgamation of true,quasi-true, or completely fictional events. But the lessons? They are always real and never, ever fictional. Got that?